'In proper care, she would not have died'

CORONER Nicholas Rheinberg ruled that the staff and management of a former Widnes nursing home had committed a 'gross failure' in their attempts to provide a frail pensioner with adequate medical attention.

CORONER Nicholas Rheinberg ruled that the staff and management of a former Widnes nursing home had committed a 'gross failure' in their attempts to provide a frail pensioner with adequate medical attention.

He recorded a verdict of death by natural causes but added that gross neglect by management and staff at Norlands Park nursing home had contributed to 82-year-old Honora Derham's demise.

And he ordered the National Care Standards Committee (NCS) - the body responsible for inspecting nursing homes - should circulate advice to its members about the dangers of pressure sores, stressing that the condition should be treated quickly.

Mr Rheinberg said: 'Had Mrs Derham been given the proper care, she would not have died as a result of the pressure sores she contracted.'

And he blasted the way Norlands Park had been run by owner Norman Hurst and his daughters Susan Thompson and Linda Veriman.

He said: 'There was a clear failure to keep proper medical records and a clear failure to take the right course of action. Standards of care were woefully inadequate. There was a gross failure to provide basic medical treatment to a dependent person.

'When she was taken to hospital, doctors were shocked by what they discovered.

'They said Mrs Derham's was the worst such case they had ever encountered.'

Although Norlands Park closed last year, Mr Hurst still runs a nursing home in Cumbria.

The Warrington inquest heard that the sisters running the home had no medical training. In fact, they numbered only a handful of computer and secretarial qualifications between them.

Susan Thompson admitted the home had no business plans and there were little or no financial controls.

She also confessed that she did not know how long medical records should be kept.

She denied claims of under-staffing at the home but added: 'We were not aware of any staff problems, we kept to the minimum standards at all times.

'Sometimes people would have to do double shifts if staff rang in sick.'

But Mr Rheinberg said: 'It is clear that people were working more than was healthy for them and that sometimes people were going off sick because of stress.'

In the days following Mrs Derham's death, staff were called to a meeting by Ms Thompson and warned not to talk to anyone about the incident or they would be sacked.

William Horton, a nurse specialist in tissue viability at Wirral's Arrowe Park Hospital, examined the care plan, assessment documents and daily care records on Mrs Derham drawn up by nursing home staff.

He found that records had been incorrectly kept on how often the patient was turned to avoid bed sores and the wrong kind of mattress had been prescribed.

He said: 'The standard of records and reports was poor and inadequate.'

And in response to evidence that matron Jane Yelland had destroyed vital medical records, he added: 'Documents such as fluid charts are a vital part of the nursing record.

'I would be surprised to hear of any registered nurse who was not of that view.'

NCS inspector Ann Matthewson told the hearing that Norlands Park had been inspected on a number of occasions but only minor infringements in the regulations, such as a missing bath plug, had been detected.

Mr Rheinberg said he was unable to record a verdict of unlawful killing because it was impossible to blame a single individual for Mrs Derham's death.

However, he stressed that, in his opinion, there was little doubt that the neglect she suffered at Norlands Park had led to her death.